- Email: [email protected]
Pentazocine and neonatal withdrawal symptoms
Volume 85 Number 5
3.
Letters to the Editor
Feigin RD, and Fiascone A: Hematuria and proteinuria associated with methicillin administration, N Engl J Med 279:903, 1965.
The dangers of phototherapy and the "urgent warning"from the FDA To the Editor: I believe the following letter from Mr. Gerald Leavitt, Hospital Administrator, St. Peter's Hospital, Helena, Montana, would be of interest to physicians who read the recent widely publicized "urgent warning" from Dr., Elder of the Food and Drug Administration (FDA) (J Pediatr 84:145, 1974) regarding the dangers of phototherapy. The article as presented is essentially incorrect. The attending physician, having noted erythema in two neonates, requested of our State Department of Health that a test of the ultraviolet radiation of our phototherapy lamps be made. This testing equipment was not immediately available so our State Department contacted the Bureau of Radiological Safety in order to secure such equipment. Rather than send this equipment the Bureau immediately sent the equipment and an operator and did "test" the light being emitted by the fluorescent tubes. It was thee determination of this equipment operator that the ultraviolet radiation was sufficient to cause erythema in neonates over a twenty-four hour period. To this point the story as reported is essentially correct; however, other information related both to the FDA and the publisher of the article was ignored. First, it was determined by the attending physician and others subsequent to the initial request for light testing and prior to testing by the FDA, that the erythema was not caused by phototherapy. It was determined beyond doubt that the erythema was of a systematic origin and was not in any way connected with ultraviolet radiation. Second, the fluorescent light configuration which was tested has been in use for more than five years. During that period of time no recorded incident of erythema due to light radiation has been recorded nor has there been, in the recollection of any pediatrician serving this hospital, any such incident which might not have been recorded. I am concerned about the widespread dissemination by government agencies of warnings which turn out to be of highly questionable value.
Dr. JeroM F. Lucey Editor-in-Chief Pediatrics Mary Fletcher Hospital Burlington, Vt. 05401
Reply To the Editor: It was not our intent to advise physicians when to use or how to/use phototherapy but to recommend correct shielding devices.
735
As we noted in the advisory, we believe shielding material should be installed when such are not present between the infant and the light source. We are gratified that the Committee on F e t u s and N e w b o r n of the A m e r i c a n A c a d e m y of Pediatrics, in addressing the question of unshielded, homemade units, endorses this position by stating "It is absolutely imperative that any homemade fixture incorporate such a plastic filter." The Committee further stated... "The use of certain standards will automatically prevent the ultraviolet radiation which probably caused the reported erythema of the infant's skin." We concur with both recommendations. From the responses received since the release appeared, we have concluded that some, but by no means all, physicians are unclear as to the radiations emitted by lamps they are using, the spectral irradiances useful in treatment of hyperbilirubinemia, and properties of the materials interposed, if any, between the lamp and the infant. To those raising such questions, we have attempted to provide necessary information. I believe the Bureau of Radiological Health, Food and Drug Administration advisory to be scientifically well-founded and, in addition, I would point out that even if reports of erythema by the attending physicians were premature or incorrect, the measured levels of ultraviolet radiations were such that production of erythema could have occurred. Exposure to unnecessary ultraviolet radiations, we believe, should be avoided for obvious reasons. The present practice of phototherapy, as evidenced by the published statement of the Committee, requires no ultraviolet exposure. The intent of our message was to make this important point clear to any who still might not appreciate it. We find no reason at this time to retract or modify a recommendation which is consistent with good medical practice using safe medical devices.
Robert L. Elder, Sc.D. Deputy Director Bureau of Radiological Health Food and Drug Administration Department o f Health, Education, and Welfare Rockville, Md. 20852
Pentazocine and neonatal withdrawal symptoms To the Editor." We read with interest the report of Goetz and Bain, "Pentazocine and Neonatal Withdrawal Symptoms," in the June issue. We would tike to add one further case of possible pentazocine withdrawal in the newborn period. This mother had been taking 300 mg of pentazocine (Talwin) and 5-6 gm of glutethimide (Doriden) daily throughout her pregnancy. Five days prior to delivery she was begun on methadone and pentobarbitol as a withdrawal regimen. After an uneventful labor, she delivered a normal, female infant weighing 2,900 gm. The baby had Apgar scores of 8, 9, and 9.
736
Letters to the Editor
The Journal o f Pediatrics November 1974
Marked hyperirritability, increased muscle tone, and tremors were noted during the first 4 hours of life. Diaphoresis and diarrhea were manifest at 12 hours. Samples of maternal blood and urine as well as infant blood and urine were obtained for chromatographic analysis. The infant was started on methadone and there ensued prompt relief from the above symptoms. Analysis of the baby's urine revealed trace amounts of pentazocine. Glutethimide was not found. Giutethimide withdrawal, according to unpublished observations, may produce symptoms similar to narcotic withdrawal. However, glutethimide's pharmacologic similarity to barbituares suggests that methadone should not be expected to relieve withdrawal symptoms resulting from glutethimide habituation. It is our conclusion, similar to that of Goetz and Bain, that pentazocine is habituating and can lead to neonatal narcotic withdrawal symptoms. Because of the uncertainty as to which drug may have produced this infant's problems, we had previously been reluctant to publish our observations. Drs. Goetz and Bain have strengthened our clinical impression. IncidentiaUy, the mother's reason for taking this much pentazocine was to relieve "low back pain." Glutethimide was administered for the relief of anxiety. On follow-up examination at one month of age, the infant appeared normal.
John W. Scanlon, M.D. Boston Hospital .for Women 221 Longwood Ave. Boston, Mass. 02115
d e c o m p e n s a t i o n was diagnosed. Assisted ventilation was resumed and he recovered with antibiotic treatment. Over the n e x t 4 m o n t h s , he had two other episodes of bronchopneumonia with cardiac failure and on one of these occasions, cardiac arrest with tonic seizures occurred and diphenylhydantoin, 50 mg/day, was added to the regimen. Since the end of December 1973 (age 17 months), he has had no more complications; his cardiac insufficiency is totally controlled with digoxin 0.2 rag/day, and a decrease in the size of the liver and heart has occurred. Since 20 months of age, assisted ventilation during the night was progressively shortened and finally completely stopped over a one-month period, without complications. He has maintained normal Pco 2 during sleep and has shown no signs of cardiac decompensation. For the past one and one-half months, he breathes spontaneously day and night, without assisted ventilation and he spends the weekends at home with his parents. Permanent discharge is scheduled for June 1974. Developmental progression has been very satisfactory and he walked alone from the age of 19 months. Detailed developmental testing at 20 months of age, using the Griffith scale, showed motor development of around 15 months, whereas all other performances were at the 18 months level. He has no specific neurologic signs except for mild generalised hypotonia. We believe that the progressive improvement and present neurologic status of our patient speaks strongly against a degenerative process as the basis for his congenital failure of automatic ventilation and would be in favor of delayed maturation of central respiratory mechanisms. His cardiac insufficiency is presently stationary and totally controlled.
Thierry Deonna, M.D. Wanda Arczynska, M.D. Antonio Torrado, M.D. Service de Pgdiatrie HOpital Cantonal Universitaire Lausanne, Switzerland
Congenital failure of automatic ventilation (Ondine's curse) To the Editor." The child whom we described in our paper I was 8 months old at the time of the original submission of the article. He is now 22 months old and has shown recent surprising progress which we believe should be brought to the attention of your readers, especially in view of the recent correspondence we have received concerning the possibility that our child might be suffering from Leigh's subacute necrotizing encephalomyelopathy.
REFERENCE
1.
Deonna T, Arczynska W, and Torrado A: Congenital failure of automatic ventilation ( O n d i n e ' s curse), J PEO1ATR84:710, 1974.
Maternally ingested salicylate as a cause of neonatal hemorrhage
F O L L O W - U P R E P O R T AND C O M M E N T S From age 8 to 12 months, he had no intercurrent illnesses, Could go home during the day time, and received assisted ventilation only during the night for 6 to 8hours. At age 12 months, assisted ventilation was completely stopped without initial problem. During this period, a sleep electroencephalogram with recording of respiration and eye movements was made. A normal sleep pattern was present and no apnoea occurred. After 13 days without assisted ventilation, he became cyanotic, tachypnoeic, and febrile, and bronchopneumonia with cardiac
To the Editor: Drs. Haslam, Ekert, and Gillam 1 associated hemorrhage and platelet dysfunction in a newborn infant with maternal ingestion of salicylate. Although the hemostatic defects described are consistent with aspirin-induced platelet dysfunction, the authors state that the mother had taken calcium salicylate and not acetylsalicylate (aspirin). If this were so, the platelet defects cannot be attributed to the drug ingested by the mother in that
3.
Letters to the Editor
Feigin RD, and Fiascone A: Hematuria and proteinuria associated with methicillin administration, N Engl J Med 279:903, 1965.
The dangers of phototherapy and the "urgent warning"from the FDA To the Editor: I believe the following letter from Mr. Gerald Leavitt, Hospital Administrator, St. Peter's Hospital, Helena, Montana, would be of interest to physicians who read the recent widely publicized "urgent warning" from Dr., Elder of the Food and Drug Administration (FDA) (J Pediatr 84:145, 1974) regarding the dangers of phototherapy. The article as presented is essentially incorrect. The attending physician, having noted erythema in two neonates, requested of our State Department of Health that a test of the ultraviolet radiation of our phototherapy lamps be made. This testing equipment was not immediately available so our State Department contacted the Bureau of Radiological Safety in order to secure such equipment. Rather than send this equipment the Bureau immediately sent the equipment and an operator and did "test" the light being emitted by the fluorescent tubes. It was thee determination of this equipment operator that the ultraviolet radiation was sufficient to cause erythema in neonates over a twenty-four hour period. To this point the story as reported is essentially correct; however, other information related both to the FDA and the publisher of the article was ignored. First, it was determined by the attending physician and others subsequent to the initial request for light testing and prior to testing by the FDA, that the erythema was not caused by phototherapy. It was determined beyond doubt that the erythema was of a systematic origin and was not in any way connected with ultraviolet radiation. Second, the fluorescent light configuration which was tested has been in use for more than five years. During that period of time no recorded incident of erythema due to light radiation has been recorded nor has there been, in the recollection of any pediatrician serving this hospital, any such incident which might not have been recorded. I am concerned about the widespread dissemination by government agencies of warnings which turn out to be of highly questionable value.
Dr. JeroM F. Lucey Editor-in-Chief Pediatrics Mary Fletcher Hospital Burlington, Vt. 05401
Reply To the Editor: It was not our intent to advise physicians when to use or how to/use phototherapy but to recommend correct shielding devices.
735
As we noted in the advisory, we believe shielding material should be installed when such are not present between the infant and the light source. We are gratified that the Committee on F e t u s and N e w b o r n of the A m e r i c a n A c a d e m y of Pediatrics, in addressing the question of unshielded, homemade units, endorses this position by stating "It is absolutely imperative that any homemade fixture incorporate such a plastic filter." The Committee further stated... "The use of certain standards will automatically prevent the ultraviolet radiation which probably caused the reported erythema of the infant's skin." We concur with both recommendations. From the responses received since the release appeared, we have concluded that some, but by no means all, physicians are unclear as to the radiations emitted by lamps they are using, the spectral irradiances useful in treatment of hyperbilirubinemia, and properties of the materials interposed, if any, between the lamp and the infant. To those raising such questions, we have attempted to provide necessary information. I believe the Bureau of Radiological Health, Food and Drug Administration advisory to be scientifically well-founded and, in addition, I would point out that even if reports of erythema by the attending physicians were premature or incorrect, the measured levels of ultraviolet radiations were such that production of erythema could have occurred. Exposure to unnecessary ultraviolet radiations, we believe, should be avoided for obvious reasons. The present practice of phototherapy, as evidenced by the published statement of the Committee, requires no ultraviolet exposure. The intent of our message was to make this important point clear to any who still might not appreciate it. We find no reason at this time to retract or modify a recommendation which is consistent with good medical practice using safe medical devices.
Robert L. Elder, Sc.D. Deputy Director Bureau of Radiological Health Food and Drug Administration Department o f Health, Education, and Welfare Rockville, Md. 20852
Pentazocine and neonatal withdrawal symptoms To the Editor." We read with interest the report of Goetz and Bain, "Pentazocine and Neonatal Withdrawal Symptoms," in the June issue. We would tike to add one further case of possible pentazocine withdrawal in the newborn period. This mother had been taking 300 mg of pentazocine (Talwin) and 5-6 gm of glutethimide (Doriden) daily throughout her pregnancy. Five days prior to delivery she was begun on methadone and pentobarbitol as a withdrawal regimen. After an uneventful labor, she delivered a normal, female infant weighing 2,900 gm. The baby had Apgar scores of 8, 9, and 9.
736
Letters to the Editor
The Journal o f Pediatrics November 1974
Marked hyperirritability, increased muscle tone, and tremors were noted during the first 4 hours of life. Diaphoresis and diarrhea were manifest at 12 hours. Samples of maternal blood and urine as well as infant blood and urine were obtained for chromatographic analysis. The infant was started on methadone and there ensued prompt relief from the above symptoms. Analysis of the baby's urine revealed trace amounts of pentazocine. Glutethimide was not found. Giutethimide withdrawal, according to unpublished observations, may produce symptoms similar to narcotic withdrawal. However, glutethimide's pharmacologic similarity to barbituares suggests that methadone should not be expected to relieve withdrawal symptoms resulting from glutethimide habituation. It is our conclusion, similar to that of Goetz and Bain, that pentazocine is habituating and can lead to neonatal narcotic withdrawal symptoms. Because of the uncertainty as to which drug may have produced this infant's problems, we had previously been reluctant to publish our observations. Drs. Goetz and Bain have strengthened our clinical impression. IncidentiaUy, the mother's reason for taking this much pentazocine was to relieve "low back pain." Glutethimide was administered for the relief of anxiety. On follow-up examination at one month of age, the infant appeared normal.
John W. Scanlon, M.D. Boston Hospital .for Women 221 Longwood Ave. Boston, Mass. 02115
d e c o m p e n s a t i o n was diagnosed. Assisted ventilation was resumed and he recovered with antibiotic treatment. Over the n e x t 4 m o n t h s , he had two other episodes of bronchopneumonia with cardiac failure and on one of these occasions, cardiac arrest with tonic seizures occurred and diphenylhydantoin, 50 mg/day, was added to the regimen. Since the end of December 1973 (age 17 months), he has had no more complications; his cardiac insufficiency is totally controlled with digoxin 0.2 rag/day, and a decrease in the size of the liver and heart has occurred. Since 20 months of age, assisted ventilation during the night was progressively shortened and finally completely stopped over a one-month period, without complications. He has maintained normal Pco 2 during sleep and has shown no signs of cardiac decompensation. For the past one and one-half months, he breathes spontaneously day and night, without assisted ventilation and he spends the weekends at home with his parents. Permanent discharge is scheduled for June 1974. Developmental progression has been very satisfactory and he walked alone from the age of 19 months. Detailed developmental testing at 20 months of age, using the Griffith scale, showed motor development of around 15 months, whereas all other performances were at the 18 months level. He has no specific neurologic signs except for mild generalised hypotonia. We believe that the progressive improvement and present neurologic status of our patient speaks strongly against a degenerative process as the basis for his congenital failure of automatic ventilation and would be in favor of delayed maturation of central respiratory mechanisms. His cardiac insufficiency is presently stationary and totally controlled.
Thierry Deonna, M.D. Wanda Arczynska, M.D. Antonio Torrado, M.D. Service de Pgdiatrie HOpital Cantonal Universitaire Lausanne, Switzerland
Congenital failure of automatic ventilation (Ondine's curse) To the Editor." The child whom we described in our paper I was 8 months old at the time of the original submission of the article. He is now 22 months old and has shown recent surprising progress which we believe should be brought to the attention of your readers, especially in view of the recent correspondence we have received concerning the possibility that our child might be suffering from Leigh's subacute necrotizing encephalomyelopathy.
REFERENCE
1.
Deonna T, Arczynska W, and Torrado A: Congenital failure of automatic ventilation ( O n d i n e ' s curse), J PEO1ATR84:710, 1974.
Maternally ingested salicylate as a cause of neonatal hemorrhage
F O L L O W - U P R E P O R T AND C O M M E N T S From age 8 to 12 months, he had no intercurrent illnesses, Could go home during the day time, and received assisted ventilation only during the night for 6 to 8hours. At age 12 months, assisted ventilation was completely stopped without initial problem. During this period, a sleep electroencephalogram with recording of respiration and eye movements was made. A normal sleep pattern was present and no apnoea occurred. After 13 days without assisted ventilation, he became cyanotic, tachypnoeic, and febrile, and bronchopneumonia with cardiac
To the Editor: Drs. Haslam, Ekert, and Gillam 1 associated hemorrhage and platelet dysfunction in a newborn infant with maternal ingestion of salicylate. Although the hemostatic defects described are consistent with aspirin-induced platelet dysfunction, the authors state that the mother had taken calcium salicylate and not acetylsalicylate (aspirin). If this were so, the platelet defects cannot be attributed to the drug ingested by the mother in that